Use of extracorporeal membrane oxygenation in combination with high-frequency oscillatory ventilation in post-traumatic ARDS

Extracorporeal membrane oxygenation in trauma: A single institution experience and review of the literature

INTRODUCTION:

Limited options exist for cardiovascular support of the trauma patient in extremis. This patient population offers challenges that are often considered insurmountable. This article identifies a heterogeneous group of trauma patients in extremis who may benefit from extracorporeal membrane oxygenation.

METHODS:

Data were sourced from the medical records of all patients placed on extracorporeal membrane oxygenation following trauma at a Level I Trauma Center between 1 December 2016 and 1 December 2017.

RESULTS:

All patients were male (N = 7), mostly with blunt injuries (n = 5), with an average age of 41 years and with an average Injury Severity Scores of 33 (median = 34). Two out of seven patients survived (28.5%). Survivors tended to have a longer duration on extracorporeal membrane oxygenation (13.5 vs 3.8 days), had extracorporeal membrane oxygenation initiated later (15 vs 7.8 days), and had suffered a blunt injury. Two patients were initiated on veno-arterial extracorporeal membrane oxygenation (both non-survivors) and five were initiated on veno-venous extracorporeal membrane oxygenation (two survivors, three non-survivors). Five patients were heparinized immediately (one survivor, four non-survivors), and two patients were heparinized after clotting was noted in the circuit (one survivor, one non-survivor). Three of the seven (42.8%) patients suffered cardiac arrest either prior to, or during, the initiation of extracorporeal membrane oxygenation (all non-survivors).

DISCUSSION:

Extracorporeal membrane oxygenation use in the trauma patient in extremis is not standard; however, this article demonstrates that extracorporeal membrane oxygenation is feasible in a complex, heterogeneous patient population when treated at designated centers.

48 h cessation of mechanical ventilation during venovenous extracorporeal membrane oxygenation in severe trauma: a case report

A 32-year-old motorcyclist who was hit by a tram subsequently presented with blunt force thoracic trauma, a pelvic fracture and a penetrating injury to the left lower extremity. Coagulopathy persisted following surgery of the leg and pelvic vascular intervention. Bedside thoracotomy was performed to treat pneumothorax and pneumopericardium. Severe hypoxemia secondary to lung failure ensued, which required venovenous extracorporeal membrane oxygenation (VV ECMO) support. On the third day after the trauma, ultra-protective mechanical ventilation was not possible due to non-existent lung compliance; thus, the ventilator was disconnected, and the T-piece was connected to the blocked tracheal tube left in the airway. Gas exchange occurred via VV ECMO separately. After 48 h of cessation of ventilator support, the patient was weaned from sedation. At this time, respiratory effort was observed, and assisted ventilation was initiated. The patient ultimately recovered and experienced an excellent outcome. The clinical significance of zero end-expiratory pressure (ZEEP) and the complete cessation of open lung strategy during ECMO remains controversial. In cases of reduced lung compliance, if VV ECMO can facilitate adequate gas exchange, the discontinuation of ventilation is an option that can be used to prevent ventilator-induced lung damage and to allow the lungs to rest. VV ECMO is feasible as lung support with no mechanical ventilation in case of severe lung failure after major trauma.

Management of blunt pulmonary injury

Thoracic injuries account for 25% of all civilian deaths. Blunt force injuries are a subset of thoracic injuries and include injuries of the tracheobronchial tree, pleural space, and lung parenchyma. Early identification of these injuries during initial assessment and resuscitation is essential to reduce associated morbidity and mortality rates. Management of airway injuries includes definitive airway control with identification and repair of tracheobronchial injuries. Management of pneumothorax and hemothorax includes pleural space drainage and control of ongoing hemorrhage, along with monitoring for complications such as empyema and chylothorax. Injuries of the lung parenchyma, such as pulmonary contusion, may require support of oxygenation and ventilation through both conventional and nonconventional mechanical ventilation strategies. General strategies to improve pulmonary function and gas exchange include balanced fluid resuscitation to targeted volume-based resuscitation end points, positioning therapy, and pain management.

Percutaneous dilatational tracheostomy (PDT) in trauma patients: a safe procedure

PURPOSE

Percutaneous dilatational tracheostomy (PDT) is a standard procedure routinely performed on intensive care units. While complication rates and long-term outcomes have been studied in different patient populations, there are few studies known to these authors involving PDT in trauma patients and the complications which may result.

METHODS

Between March 2007 and August 2013, all instances and peri-procedural complications during PDT occurring on the trauma intensive care unit, a unit specialized in the care of injured patients and especially polytrauma patients, were documented. PDTs were performed by a surgeon with the assistance and supervision of another, using bronchoscopic guidance performed by the respiratory medicine department.

RESULTS

289 patients were included in the study, 225 men and 64 women with a mean age of 49 ± 21 years. Complications occurred in 37.4 % of cases. The most common complication, bleeding, occurred in 26.3 % of patients ranging from little to severe bleeding. Fracture of tracheal cartilage occurred in 6 % of PDT cases. Additional complications such as dislocation of the guidewire, hypotension, and oxygen desaturation were observed. Most complications did not require treatment. The second tracheal intercartilaginous space was successfully intubated in 82 % of cases.

CONCLUSIONS

PDT is a safe procedure in trauma patients. When considering the severity of complications such as major blood loss, pneumothorax, or death, this evidence suggests that PDT is safer in trauma patients compared to other patient cohorts.

High-frequency percussive ventilation: a new strategy for separation from extracorporeal membrane oxygenation

We report the case of a 48-year-old woman who developed severe septic shock and lung injury after community-acquired pneumonia. She was supported on arteriovenous extracorporeal membrane oxygenation (ECMO) for 19 days. To facilitate decannulation and separation from ECMO, we began trials of high-frequency percussive ventilation (HFPV) using the volumetric diffusive respiration ventilator VDR-4 (Percussionaire Corp, Sandpoint, Idaho) for 4 consecutive days (1 before and 3 after). Decannulation was achieved successfully, and the patient was transferred to the floor 3 months later. During the 4 days of HFPV, the chest radiograph improved, as did gas exchange and clearance of pulmonary secretions. HFPV may be a promising strategy for improving lung recruitment and airway clearance during separation from ECMO in the critically ill patient.

Extracorporeal membranous oxygenation (ECMO) in polytrauma: what the radiologist needs to know

The purpose of this article is to review the spectrum of severe traumatic injuries treatable with ECMO and their imaging features, considerations for cannula placement, and complications that may arise in polytraumatized patients on extracorporeal life support. Recent major advances in miniaturization and biocompatibility of ECMO devices have dramatically increased their safety profile and expanded the application of ECMO to patients with severe polytrauma.

High-frequency oscillation ventilation for hypercapnic failure of conventional ventilation in pulmonary acute respiratory distress syndrome

Introduction

High-frequency oscillation ventilation (HFOV) is regarded as particularly lung protective. Recently, HFOV has been shown to be not beneficial for acute respiratory distress syndrome (ARDS) patients in general. Due to its special physical effects, it could be beneficial, however, in inhomogeneous ARDS. This study evaluates the effect of HFOV on PaCO₂ removal in hypercapnic patients with ARDS of pulmonary origin.

Methods

Between October 2010 and June 2014 patients with ARDS of pulmonary origin with PaO₂/FiO₂ ratio >60 mmHg, but respiratory acidosis (pH <7.26) under optimized protective ventilation were switched to HFOV, using moderate airway pressure (adopting the mean airway pressure of the prior ventilation). Data from these patients were analyzed retrospectively; PaCO₂ and pH before, 1 h and 24 h after the start of HFOV were compared.

Results

Twenty-six patients with PaO₂/FiO₂ ratio 139 ± 49 and respiratory acidosis (PaCO₂ 68 ± 12 mmHg) were put on HFOV after 17 ± 22 h of conventional ventilation. Mean airway pressure was 19 cm H₂O (15 to 28). PaCO₂ decreased significantly: after 1 hour the mean difference was −14 ± 10 mmHg; P <0.01 and after 24 hours −17 ± 12 mmHg; P <0.01; n = 24. CO₂ clearance improved in all but two patients; in those, extracorporeal lung support was initiated. Oxygenation remained unchanged after 1 h and slightly increased after 24 h. No complications related to HFOV were observed. Twenty-two patients improved and could be weaned from HFOV. Twenty patients (77%) were alive on day 30.

Conclusions

HFOV could be a useful alternative in patients with ARDS of pulmonary origin with hypercapnic failure of lung-protective conventional ventilation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0935-4) contains supplementary material, which is available to authorized users.

The use of double lumen cannula for veno-venous ECMO in trauma patients with ARDS

Background

The use of a double lumen cannula for veno-venous extracorporeal membrane oxygenation (v.v. ECMO) offers several advantages such as cannulation with only one cannula, patient comfort and the earlier mobilization and physiotherapy. The cannulation should be performed under visual wire and cannula placement into the right atrium, which is associated with risks of malposition and right ventricular perforation. The aim of this patient series is to describe the use of double lumen cannula in trauma patients with posttraumatic ARDS.

Material and methods

Criteria for the v.v ECMO treatment were defined as hypoxaemia (pO2/FiO2 < 200 mmHg, FiO2 0.8-1,0); tidal volume >4-6 ml/kg ideal body weight; mean inspiratory pressure (Pinsp) >32-34 mmHg; respiratory acidosis pH <7.25; and arterial saturation (SaO2) <90%. The analysis included the Injury Severity Score (ISS), the types of injury, time of treatment, complications and outcomes.

Results

A total of 24 patients with major trauma were treated for posttraumatic ARDS with v.v. ECMO. The double lumen cannula (Avalon®, Fa. Maquet, Rastatt, Germany) was used in six male patients. The mean ISS was 31 (20–48). The ECMO therapy was started in an average on the third day after trauma. The mean ECMO run time was 7 days ± 5 (6–18), and the hospital stay was in mean of 60 days ± 34 (21–105).

Conclusion

The use of double lumen cannula for v.v ECMO therapy in trauma patients is a feasible treatment option. No higher risk of bleeding could be found in this case series. A PTT-controlled heparinization is recommended using double lumen cannula. Therefore the use of this cannula type in trauma patients with high risk of bleeding is to discuss controversially.

Is the use of high frequency oscillatory ventilator beneficial in managing severe chest injury with massive air leak?

Severe thoracic trauma can be associated with immediate life-threatening injuries including major air leak syndrome that can lead to acute respiratory failure and refractory hypoxaemia. Such injuries invariably require thoracotomy following failure of conventional ventilation strategy and paucity of other non-operative interventions. We describe a case in which we used high frequency oscillatory ventilation (HFOV) as a part of management of such injury and averted the need for thoracotomy.

Management of Blunt Pulmonary Injury

Thoracic injuries account for 25% of all civilian deaths. Blunt force injuries are a subset of thoracic injuries and include injuries of the tracheobronchial tree, pleural space, and lung parenchyma. Early identification of these injuries during initial assessment and resuscitation is essential to reduce associated morbidity and mortality rates. Management of airway injuries includes definitive airway control with identification and repair of tracheobronchial injuries. Management of pneumothorax and hemothorax includes pleural space drainage and control of ongoing hemorrhage, along with monitoring for complications such as empyema and chylothorax. Injuries of the lung parenchyma, such as pulmonary contusion, may require support of oxygenation and ventilation through both conventional and nonconventional mechanical ventilation strategies. General strategies to improve pulmonary function and gas exchange include balanced fluid resuscitation to targeted volume-based resuscitation end points, positioning therapy, and pain management.